Site Search Navigation

Site Navigation

Site Mobile Navigation

Nursing Homes for the Rest of Us

By Jane Gross February 25, 2009 11:52 amFebruary 25, 2009 11:52 am

Monika Graff for The New York TimesFrom left, physical therapist Miriam Parness leading residents Mack Savid, Hyman Martin and Ken Hornreich in light exercise at the Jacob Reingold Pavilion at the Hebrew Home for the Aged in Riverdale, N.Y. For more pictures, click here.

One snowy New Year’s Eve, in a cabin by Lake George in upstate New York, Dan Reingold, the 54-year-old C.E.O. of the Hebrew Home for Aged in Riverdale, shared a bottle of single-malt Scotch with a group of friends and asked them to imagine a nursing home that wouldn’t make baby boomers like themselves say, “Over my dead body.”

He was already running one of the nation’s finest skilled nursing facilities, the one where my late mother lived the last two years of her life. But men and women who came of age during World War II and the Depression were a breed onto themselves. They put up with double rooms, showers down the hall, linoleum floors and coffee that arrived at the breakfast table lukewarm from a central kitchen. They tolerated all of this, in my experience, better than their adult children, who had vastly higher expectations and loads of guilt.

This physical environment that my mother never complained about left me weeping in the car on the way home from each visit. What kind of daughter abandons her mother to such a fate? Even after I came to appreciate the quality of care she was receiving, and my brother and I received as well, the place itself, while spotlessly clean, stirred in me a sense of failure that never went away. I’ve described it here often, to Mr. Reingold’s dismay.

He wishes I’d lighten up on the accounts of wheelchairs hubcap-to-hubcap in the lounge, and instead point my gaze to the facility’s sweeping views of the Hudson River, south past the George Washington Bridge to the tip of Manhattan, where the Twin Towers once stood. Or better yet, he often has said, I should come take a look at the new building, named for his late father Jacob Reingold, who ran the Hebrew Home before him, which had been a construction site when my mother died in 2003.

The Jacob Reingold Pavilion, which I’ve now visited, is the result of Mr. Reingold’s informal focus group in Lake George. At the time, a more conventional version of that building was already on the drawing board, approved by the board of directors and expected to cost $24 million. But as his friends answered the question, “What do we want?,’’ Mr. Reingold took notes and reconsidered.

Private rooms. Internet access. A fitness center. Massage rooms. Kitchens in each dining area, so the coffee is hot and the toast crispy. Electronic medical records to eliminate the need for nursing stations. Windows that face the river, positioned so someone in a wheelchair can enjoy the view. And showers in each room to eliminate the indignity of being wrapped in a sheet and wheeled down the public hallway.

He scrapped the existing project, asked his board to approve a new building that would cost $50 million and raised the money privately. “What we tried to do is move the bar,’’ he said, “make it as good as it can be. This is where long-term care needs to go before it’s you and me. What I designed here is a clinically supportive environment that doesn’t look, feel or smell clinical.”

“I look at it and say to myself, ‘If i needed nursing care, would I live here?’ And my answer is definitely yes.”

Mine, too. In fact, it crossed my mind to wonder if I could have used the indoor swimming pool if my mother had lived there. Her floor, by the way, in an adjacent building, will soon undergo a $700,000 renovation. “We can’t do it all in one shot,’’ Mr. Reingold said. “And unfortunately, when you have to do it in stages, it’s like buying a new suit. It makes your shoes look old.”

Update 2/26/2009 | Many of you noted that a place like this must be out of the economic reach of all but the very wealthy (and no, that does not include newspaper writers!). Let me clarify something that has come up in this blog numerous times, something I have failed to communicate with clarity or precision.

Yes, nursing homes like this one are exorbitantly expensive for self-pay residents — upwards of $15,000 a month for a private room. (Yes, $15,000. Yes, per month.) But 80 percent of the people here, and at nursing homes both upscale and downscale across America, have no money because they didn’t have any to begin with, they’ve already spent it all on their own care, or they have used legal (yes, legal, however unfair or even immoral) means to transfer their money to their heirs.

All of these residents without funds are subsidized by the government via Medicaid. In other words, they reside here and at all other nursing homes for free, with Medicaid covering a smaller and smaller portion of their actual care and the nursing homes themselves making up the shortfall. Nonprofit homes are more likely than for-profits to provide identical services to those who are paying their own bills and those who aren’t. When my mother was a resident of the Hebrew Home, she paid $14,000 a month of her own money for her care for over a year. The last few months of her life she was on Medicaid, having exhausted her funds. Her excellent care was identical before and after.

One additional fact of some importance: It is illegal for nursing homes to evict self-pay residents when they run out of money. What this lengthy explanation translate to is this: Assisted living facilities, continuing care retirement communities and hourly or live-in home care are generally available only to the wealthy, since — except under special waivers, in certain states — there is no government reimbursement. Nursing homes, and only nursing homes, serve rich and poor alike, because Medicaid takes care of anyone in such a facility.

The facility looks very different from other nursing homes. But it still looks insitutional. I’d say it’s an improvement, but not good enough. And I’m not a Boomer, I’m a War Baby. That said, I also realize that my children may have no other choice, and I’d rather cut off my arm than have them suffer from having me live with them. I’ll be sure I have all this set up long in advance so that no emergency decision has to be made like the one made for my Mother-in-Law.

The challenges of the physical environment you described are exactly the types of problems that need to be resolved in order to make life in a nursing home more palatable to the next generation of residents. From the photos, it looks like the Jacob Reingold Pavilion accomplishes this. I wonder if similar care has been put into addressing the interpersonal dynamics of staff/resident interactions (see my blog post for my thoughts on this issue: //mybetternursinghome.blogspot.com/2009/01/less-hospital-more-hospitality.html).

I prefer to think of this facility as residential. Are there restrictions for the type of resident who may live there? I know it is not a SNF, but what about those with catheters, tube feedings etc?
I would like to know the cost of living there. I would wager that few can afford it.
I am still opting for aging in place or in a senior community.
I don’t want to live in an environment outside of my control, no matter how elegant or convenient.//www.caringisnotenough.net

I wonder how many of us will be able to afford this level of care after the recent stock market debacle. The writer acts as though the cost of care played no part in the decision of where her mother or father was placed. There are plenty of luxurious accomodations for those that can afford them. However, those are the minority of our aging population and will be a lot less.

Face it: You get old, you can’t control your bladder or your bowel movements, your memory goes to heck and you actually want to complain about not getting a private room at the only facility that will accept you????

I’m a baby boomer myself, but we are the biggest nation of whiners I have ever seen.

Many, maybe most, of us Boomers, certainly single women, won’t be able to afford any type of nursing home, even of the lowest quality. I, for one, am grateful I live in a state where assisted suicide is legal, should I need it in old age. Meanwhile I take care of myself and hope I’ll retain my health and faculties, then go peacefully, without being a burden to family, preferably at home.

My mom lived in a good nursing home with bath off every room. The food was tasty (pureeing is an art form) and there were no hubcap to hubcap wheelchairs. There was a nice terrace and a good front porch. This isn’t so innovative. Fact is, she wasn’t that aware of her surroundings, it was mainly for us her family that we could say, For the way she was she was as well off as possible. It was her dementia and crippled condition that made her old age sad. She could enjoy life, however, and she wasn’t so badly off as the paralytics on the upper floor.
Just smother me with a pillow.

Social security is not enough to live on for most of us–especially the 60 percent or so who were never paid enough to amass stock portfolios and large savings accounts. Medical care devours what we have managed to save. And the 401-Ks for those lucky enough to have them are tanking.

We may be lucky to have double rooms and food before long. I hope that those who are young can withstand the mean-spirited appeals of those who would gut social security further.

Sadly, any large-scale investment and innovation by a “Cadillac of nursing homes” stands little chance of reforming the rest of them, the Hyundais and Yugos of nursing homes, for cost reasons alone. (We’ve been down this road aways before with the “culture change” movement.) And ultimately, even infrastructure design cannot change the most devastating deficiency in NHs: the human factor. The apparent motto of every NH I’ve ever visited: “Not much nursing…not much home.” If the depressing clinical environment were coupled with superb medical care, that’d be something, at least; or if the wretchedly disconnected and mediocre clinical care were linked to warm and home-like surroundings, ditto. It’s not architecture or interior design, but people–from the disinterested physicians to the callous majority of underpaid, ill-trained aides–who create that wondrous death-in-life that leaves us weeping in the parking lot after visiting Mom and Dad. If you could guarantee me a NH with 100% caring, compassionate staff–or hell, even 80% and the rest guaranteed to be at least non-abusive–why, I’d take a semi-crappy physical plant if I had to. Even a “spa” run by people who treat their charges like children at best and detainees at worst is still a prison. Ultimately, our treatment of the elderly reflects our values as a society. I am not optimistic that Mr. Reingold’s values will translate easily beyond his little paradise on the Hudson.

This sounds wonderful, and like a good idea to have friends gather for ideas.

OTOH – there are other elements to having this work.

I placed my mother in the gem of Florida nursing homes, after a 6-month waiting list, and was thrilled and felt fortunate. The night she died, I tried desperately to get the staff to call a doctor. I never knew what “clammy” meant before touching her hands, while seeing sweat on her forehead.

The doctor, who took my call, told me, in these words, “I’d have to drive back 30 miles again to get there and I don’t feel like it.”

Then the battle began, with the trained nurses and staff, who had so many protocols to follow that it took them about an hour and a half to finally call an ambulance, while I desperately tried all I could – pay phones were broken, no one had a cell phone (it was around 10 years ago; people had them but not everyone).

The paramedics said I was absolutely right to have called; my mother died that night, of pneumonia never diagnosed in the best nursing home in Florida.

This is not to present one of what I’m sure could be a flood of stories; it’s to say, in addition to being in a place where our stomach doesn’t turn over from the things you mentioned, and others – it is, after all, the care needed in an emergency, its availability, that counts.

Maybe I’m too far away from old age but it seems to me, everything in the pictures and in this post assume the residents want to consume without being productive themselves. You can go to a concert, do yoga, get a massage… What about interacting with other generations? What about being able to volunteer your wisdom or abilities? I once heard that Universities were setting up retirement facilities on campus to allow retirees to interact with other generations, go to classes, work… It would be nice if this ability to continue to grow and contribute extended throughout life. Even if you can’t do much, being able to contribute to the world around you seems like a necessary requirement to living a good life.

The Hebrew Home should take a look at their independent living quarters called Riverwalk. The food is depressing, their is no 24 person at the front desk, transportation is limited to a few square miles and it is expensive.

Private rooms aren’t so obvious at all. For a mostly non-mobile resident, talking to the roommate might be the bulk of the interaction all day. While not perfect, it’s a nice interlude to staring at the wall or a watching a TV screen all day.

I watched this happen to my aunt. She lived alone most of her life, and when she finally entered a nursing home she was initially place in a double. Eventually a single room finally opened up, and she refused it. Not because she was great friends with her roommate, but because otherwise she would have been totally isolated in a strange environment for most of the day.

So the improved facility costs more than twice as much as the one originally planned. How can we pay for that since we can’t afford the inadequate care we get now? Something has to seriously give way. Our financial structure is already crumbling, and we haven’t begun to address the much larger costs of medicare, medicaid, and looming retirements that face us.

one of the reasons my mother refuses to go to a nursing care facility is lack of privacy. She is of the World War II generation. They fought for their freedom-our freedom. She dosen’t want to be ‘herded” anywhere. She doesn’t want to be told what to do, when to sleep, when to eat. She would rather be alone-in heer own home. Freedom of choice. Privacy is an issue=and rightfully so.

If we are very lucky, the “rest of us” are more likely to end up in the kind of subsidized senior housing, a highrise of small apartments, that is across the street from my house. The places seem okay but not luxurious — no pool or massage room for sure. People hire aides when they need care, but those who are mobile can walk to the bakery, the post office and the grocery. It’s good exercise that’s do-able even with a walker. Most of the residents could not afford the facility described in this article. Then, again, maybe they are better off.

“One snowy New Year’s Eve, in a cabin by Lake George in upstate New York, Dan Reingold, the 54-year-old C.E.O. of the Hebrew Home for Aged in Riverdale, shared a bottle of single-malt Scotch with a group of friends and asked them to imagine a nursing home that wouldn’t make baby boomers like themselves say, ‘Over my dead body.'”

I am always fascinated by the inclusion of details like that in the desciption above concerning the sharing of a bottle of single-malt Scotch at Dan Reingold’s get-together on Lake George. Do we need to know about that single malt Scotch? Why? What if the TImes said simply they shared a bottle of Scotch? Isn’t that the equivalent of saying they shared a bottle of wine or had a beer? Or would saying simply it was “Scotch” imply they were down-scale folks, maybe even people who should pay more attention to their drinking habits. Perhaps adding “single-malt” is intended to reassure us baby boomers that these folks (and by extension, their nursing home) are true connoisseurs of the finest things in life. I know what this reminds me of — the pr speak one normally associates with promotional materials for aspirational real estate developments.

My mother never lived in a nursing home. But she did spend a couple of years in an overrated assisted living place in Manhattan. She didn’t like living in an old people ghetto, and never adjusted to the frequent deaths (it never occurred to me before I encouraged her to move there how depressing it would be to live in a building where people were dying all the time; I know it would depress me if my apartment building had more than the usual handful of miscellaneous deaths and suicides we have every year). I finally realized one of the things my mother missed most was younger people she had interacted with at her previous home in Massachusetts ( the silly singing and flower-making schoolchildren who visited her AL place were no substitute and merely served to remind her whe was in an old folks’ place). I think the ideal for my mother would have been to move into an NYU dorm. She would have much preferred living among young people (or even middle-aged people) to river views and massage therapy.

Several people have commented on costs at the Hebrew Home. For people who self-pay, I believe the Hebrew Home probably costs an average of $14,000-$15,000 a month. However, it does take Medicaid patients, and New York State has one of the highest Medicaid nursing home reimbursement rates (about $5,500 monthly, according to a recent news report), as well as one of the greatest populations of elderly Medicaid recipients in the USA (All those smart baby boomer kids, including, I have heard, former Gov. George Pataki, know all the ins and outs of “preserving assets” and getting their parents on Medicaid).

Julianne Moore gives a wonderful performance in “Still Alice,” but the film skirts the truth about dementia.Read more…

About

Thanks to the marvels of medical science, our parents are living longer than ever before. Most will spend years dependent on others for the most basic needs. That burden falls to their baby boomer children. The New Old Age blog explored this unprecedented intergenerational challenge. Paula Span will continue to write New Old Age columns twice monthly at nytimes.com/health and the conversation will continue on Twitter (@paula_span) and Facebook.